What Aetna requires for coverage
Aetna considers Home Behavioral Healthcare Services medically necessary when the following criteria (from CPB 0730) are met:
- Aetna considers provision of skilled behavioral health services in the home medically necessary when ALL of the following criteria are met:
- The services are ordered by a physician or independently licensed behavioral health professional (BHP) (e.g., psychiatrist, psychologist, social worker or professional counselor licensed to practice without supervision) and are directly related to an active treatment plan of care established by the physician or licensed BHP
- The skilled behavioral health care is appropriate for the active treatment of a condition, illness or disease
- The skilled behavioral health care is intermittent or hourly in nature (defined as a visit of up to 1 hour in duration)
- The skilled behavioral health care is provided under the supervision of an independently licensed BHP
- The services are provided in lieu of a continued hospitalization, confinement in a residential treatment facility (RTF), or receiving outpatient services outside of the home
- The treatment provided is appropriate for the member's condition including the amount of time spent providing the service as well as the frequency, type and duration of the services
- The behavioral health services provided are not primarily for the comfort or convenience of the member or family or custodial in nature
How to appeal this denial
Frame your appeal around the specific criterion you satisfy. Quote the CPB 0730 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Aetna either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.
Source: Aetna medical policy CPB 0730 — view the published policy.